In Reference to Preoperative Sinus Computed Tomography Scan Review Checklist

Abstract

I have read with great interest the article entitled “Preoperative Sinus Computed Tomography Scan Review Checklist” by Spielman and Gudis, which proposes a novel checklist for imaging reviewing prior to sinus surgery. Although the checklist addresses the relevant anatomical features and existence of prior sinus surgery or disease adequately, I feel it could be further improved regarding the position of the uncinate process, specifically in the context of the silent sinus syndrome (SSS). The silent sinus or “imploding antrum” syndrome is defined as mostly unilateral spontaneous enophthalmos and hypoglobus secondary to collapse of the orbital floor in patients with asymptomatic maxillary sinusitis. The etiology is controversial, but obstruction of the ostiomeatal complex, followed by hypoventilation and the resulting negative pressure in the maxillary sinus is considered as the principal cause of the SSS. Radiographic findings include inward retraction of the ipsilateral maxillary sinus walls, with or without opacification, lateralization of the uncinate process and middle turbinate, and infundibular occlusion. The current treatment consists of establishing adequate maxillary sinus ventilation and drainage using endoscopic middle meatal antrostomy, and restoring the normal orbital anatomy by orbital floor reconstruction. Some patients will experience recovery of the enophthalmos with the antrostomy alone, without an additional ophthalmic procedure. However, uncinectomy as a part of antrostomy in the SSS can be quite challenging, as the uncinate process is usually lateralized and may be quite unrecognizable on endoscopy or adherent to the inferomedial orbital angle. Furthermore, downward displacement and dehiscence of the orbital floor carry the additional risk of inadvertent orbital injury during the surgery. Although defining maxillary sinus as “hypoplastic” according to the proposed checklist classification (especially if unilateral) may imply the diagnosis of SSS, the description of the uncinate process exclusively by its insertion offers little information in this particular clinical scenario, where the single most important surgical step is the proper identification and removal of the uncinate process. This is further emphasized as this maneuver carries a significant risk of iatrogenic injury to the orbital contents. Therefore, the addition of classifying the position of the uncinate process in relation to the medial orbital wall as “normal” or “atelectatic/lateralized” might avoid oversimplification and could further improve the existing checklist.